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136 Cards in this Set

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The upper esophageal sphincter (UES) is in a state of tonic contraction, what is the resting pressure of this sphincter
a) 15 - 60 cm H2O
b) 3 - 5 cm H2O
c) 100 - 150 cm H2O
d) none of these
a) 15 - 60 cm H2O
What is the function of the UES
a) prevent air from entering esophagus
b) prevent aspiration
c) both of these
d) none of these
c) both of these
True/False UES function is impaired during both normal sleep and anesthesia
True
Most anesthetics will impair UES tone with one exception
a) thiopental
b) propofol
c) succinylcholine
d) ketamine
d) ketamine
Lower esophageal sphincter (LES) resting tone is
a) 35 - 45 cm H2O
b) 10 - 15 cm H2O
c) 3 - 5 cm H2O
d) none of these
b) 10 - 15 cm H2O
True/False Lower esophageal sphincter (LES) is the major barrier to gastroesophageal reflux
True
Besides drugs what other factors can reduce LES?
a) cricoid pressure
b) obesity
c) pregnancy
d) hiatal hernia
e) all of the above
e) all of the above
True/False Nondepolarizing muscle relaxants increase LES just like Sux dose
False
NDMR's have NO EFFECT on LES
True/False Barrier pressure is the difference between lower esophageal pressure and gastric pressure
True
True/False Barrier pressure is more important than LES tone in the production of gastroesophageal reflux
True
The highest risk for complications with a laparoscopic procedure is
a) when trochars are placed
b) when pt's abdomen is being insufflated
c) upon removal of trochars
a) when trochars are placed
Placement of CO2 in abdomen is called ____________________
pneumoperitoneum
True/False Hypercapnia is one of the cons of laparoscopic procedures
True, CO2 is absorbed and shows up as a high ETCO2, if greater than 55 you should increase RR to blow off CO2
Name some hemodynamic effects of laparoscopic procedures
Increase MAP,
Increase SVR (release of vasopressin/renin)
Increase HR (maybe)
increase CO, CVP (position dependent)
BRADYCARDIA
If pt should become bradycardic during laparoscopic procedure the most likely cause is ___________ How do you deal with this problem?
Vagal stimulation

Ask surgeon to stop insufflation, remove instruments from trochars to allow escape of some of the CO2
Complications of laparoscopic surgeries include
a) visceral injuries
b) vascular injuries
c) retroperitoneal bleed
d) all of the above
d) all of the above
A rare complication of laparoscopic surgeries is gas embolism, what are the signs & symptoms?
low BP
dyrhythmias
cyanosis
hypoxia
pulm edema
"mil wheel" murmur
How do you treat a gas embolism?
100% O2
stop insufflation
release CO2 from abdomen
lay pt in LEFT LATERAL position
aspirate gas through CVP
When treating a gas embolism laying your pt in left lateral position and aspirating gas from CVP is known as what
a) sellick maneuver
b) durant maneuver
c) heimlich maneuver
d) gas extraction maneuver
b) durant maneuver
If your patient is in trendelenburg what might you see hemodynamically
a) decreased venous return
b) increased venous return
c) decreased BP
d) increased BP
e) both a & c
f) both b & d
f) both b & d
During a laparoscopic cholecytectomy there is a chance for spam of sphincter of Oddi, how do you treat it?
a) narcan
b) glucagon 1 mg IV
c) Ntg 25 - 50 mcg
d) any of the above can be used
d) any of the above can be used
Your patient is having a laparoscopic nissen fundoplication performed what is the surgeon trying to repair?
a) ruptured esophagus
b) inguinal hernia
c) hiatal hernia
d) twisted bowel
c) hiatal hernia
Why is it important to mark placement and tape an NG tube when doing a laparoscopic nissen fundoplication ?
Because of the type of surgery you don't want any movement in the NG tube
What things are important to do/assess on a patient undergoing a laparoscopic colon resection?
a) assess intravascular volume status
b) check Hgb/lytes
c) place invasive monitors
d) all of the above
d) all of the above
Non metastatic carcinoid tumors can secrete ____________
hormones - serotonin, substance P, catecholamines, neurotensin, bradykinin, protstaglandins
What are the signs & symptoms of Carcinoid Syndrome?
cutaneous flushing of head, neck upper thorax
bronchoconstriction
low BP
diarrhea
What are triggers for Carcinoid Syndrome?
a) thiopental
b) sux
c) atracurium
d) morphine
e) all of the above
e) all of the above
What meds are OK to give to patients with Carcinoid Syndrome?
a) propfol, etomidate
b) vecuronium, rocuronium
c) fentanyl, sufentanil
d) none of the above
e) a, b & c
e) a, b & c
What drug can be used to treat Carcinoid Syndrome?
Octreotide (decreases production of gastropancreatic hormones)
50 - 100mcg IV/hr
or additional dosing of 25 - 50mcg IVP
Your patient is having a condyloma removed with a laser procedure, what risks are there for you? How do you protect yourself?
Exposure to Human papilloma virus from smoke plume
wear special laser mask to protect yourself!
also risk of eye damage, be sure to protect your eyes & your pts.
What is another name for aspiration pneumonitis? what causes it?
Mendelson's syndrome
aspiration of 25ml of 2.5pH gastric content
When trying to prevent aspiration of gastric contents what type of medicine would you use to decrease acidity?
a) sodium citrate
b) ranitidine
c) famotidine
d) omeprazole
e) reglan
f) all of the above
g) a, b, c & d
g) a, b, c & d
To increase gastric emptying which medicine(s) would you use
b) ranitidine
c) famotidine
d) omeprazole
e) reglan
f) all of the above
g) e only
g) e only
You are performing cricoid pressure during RSI to help prevent aspiration of gastric contents and your patient starts to vomit, what do you do?
a) apply firmer cricoid pressure
b) let go! for fear of rupture of esophagus
c) maintain steady pressure
d) place patient in trendelenburg
e) b & d
e) b & d
A person is considered "geriatric" if they are
a) 55 yo
b) 70 yo
c) 65 yo
d) 75 yo
c) 65 yo
True/False Chronologic age is more important than physiologic age
False
After the age of 30 organ function decreases linearly with age by about
a) 1%
b) 10%
c) 15%
d) none of the above
a) 1%
a 70 yo male will have a decrease of 40%
As people age it becomes more difficult for them to regulate their body temperature because
a) decrease in BMR
b) decreased autonomic peripheral vasoconstiction
c) decreased SQ tissue
d) all of the above
d) all of the above
Decreased SQ tissue increase O2 consumption by 400 -500% which can lead to
a) increased demand on CV
b) increased demand on pulmonary system
c) arterial hypoxemia
d) MI
e) all of the above
e) all of the above
True/False hypotension can ultimately lead to a silent MI
True hypotension due to loss of TBW makes pt more susceptible to a MI when receiving anesthesia and changing positions
A geriatric patient will have
a) an increased response to IV drugs
b) a decreased response to inhaled anesthetics
c) an increased response to inhaled anesthetics
d) a decreased response to IV drugs
e) both c & d
f) both a & b
e) both c & d
Elderly pts are more dependent on
what to promote a higher CO
a) decreased EDV
b) increased HR
c) increased EDV
d) decreased HR
c) increased EDV
True/False 1/2 of all elderly patients have CAD whether or not they exhibit symptoms
True
In an elderly patient reduced arterial compliance results in
a) decreased afterload
b) decreased SBP
c) increased afterload
d) none of the above
c) increased afterload
Elderly patients have a decrease in maximal HR of 1 beat per minute per year over age 50 because
a) they have a physiological beta blockade
b) a decreased sensitivity of adrenergic receptors
c) Both a & b
d) neither a or b
c) Both a & b
Elderly patients and infants are the same in that they
a) have a lesser ability to respond to hypovolemia or hypoxia with an increased HR
b) both need to be taken care of
c) have the same amount of TBW
d) they are not the same in any way
have a lesser ability to respond to hypovolemia or hypoxia with an increased HR
Normal cardiovascular changes in the elderly include
a) decreased arterial elasticity
b) increased arterial elasticity
c) decreased afterload
d) none of the above
a) decreased arterial elasticity
True/False For pts with aortic stenosis it is important to keep blood flow moving forward and a slow heart rate for good coronary perfusion
True
Elderly patients have
a) increased SNS
b) decreased SNS
c) increased PSNS
d) decreased PSNS
e) both a & d
f) both b & c
f) both b & c
True/False elderly pts blunted baroreceptor reflex may contribute to sinus node depression and syncope
True
An elderly persons pulmonary system may be effected how
a) increased FEV
b) decreased FEV
c) decreased FRC
d) increased FRC
e) both b & c
e) both b & c
You would not be surprised if your 50 year old patient had an PaO2 of
a) 80
b) 75
c) 90
d) none of the above
a) 80 formula for PaO2 change d/t aging PaO2 100 - (0.4 x 50 yo) = 80
Will your elderly patient's protective airway reflex increase or decrease?
decrease
Over all in your elderly pt there will be a increase/decrease in all of the following
RV, FRC, dead space, closing capacity, TLC, VC FEV
INCREASED RV, FRC, dead space, closing capacity

DECREASED TLC, VC, FEV
TRUE/FALSE nocturnal respiratory depression (sleep apnea syndrome) is common in elderly people
True
Will your elderly patient have a blunted or exaggerated response to hypercapnia and hypoxia
blunted
Elderly people have
a) decreased CNS activity
b) increased CMO2
c) decreased CMO2
d) very little change in the CNS other than dementia
e) both a & c
e) both a & c
When it comes to doing a spinal in an elderly pt the onset will be _______ & the duration will be _____________
faster onset
prolonged duration
Transient confusion may occur in the elderly after surgery up to how long after
a) 24 hrs
b) 48 hrs
c) 2 weeks
d) 4 weeks
c) 2 weeks
Why would you choose Robinul over Atropine or Scopolamine in an elderly patient
Because Atropine and Scopolamine are both anticholinergics that cross the BBB, and since elderly pts already have a decreased Ach, this might not be good!
In patients with Alzheimer's and Parkinson's it may be best to avoid which drugs
a) phenothiazines & reglan
b) inhalation agents, local anesthetics
c) propofol, inhalation agents
d) none of the above have an adverse reaction with those diseases
a) phenothiazines (phenergan & reglan
Your elderly patient has a decreased GFR and renal blood flow, and is also dehydrated, after induction your BP is really low and you need to treat it
which drug would you use
a) ephedrine
b) phenylephrine
ephedrine


phenylephrine would clamp down on kidneys that are already in trouble
True/False The kidney's become smaller with age and by age 80 there is a 50% loss of functioning glomeruli
True
True/False Elderly patients serum creatinine decreases by 20% by age 75 yo
False,
there is no change in the serum creatinine of elderly folks
By the age of 80 yo liver mass decreases by 40% what do you need to think about in regards to the drugs that you give?__________
Think about first pass metabolism, decreased clearance of drugs
True/False In the elderly gastric pH tends to rise while gastric emptying is prolonged
True
Why would it be important to limit the amount of glucose containing solutions in the elderly population?
b/c decreased pancreatic function
True/False (in this lecture) MAC is decreased by 4% for each decade of age after 40
True
Why might recovery of volatile anesthetics be prolonged in the elderly
b/c of an increased volume of distribution (inc. body fat), decreased hepatic function and decreased pulmonary function
When positioning elderly patients it is important to remember to pay special attention to bony prominences because
a) loss of collagen
b) decrease elasticity of tissues
c) atrophied skin damages easliy
d) all of the above
d) all of the above
Your patient lives in a nursing home and has fallen OOB and fractured her hip, when positioning her on the table you notice that both of her arms are contracted, as well as the unfractured leg, how the heck do you position her?
very carefully, position her where she lives. you will have to be creative, being careful to pad, pad, pad!
What drug(s) might you want to avoid in a patient with glaucoma?
a) sux
b) robinul
c) atropine
d) all muscle relaxants
Sux AND atropine!
True/False Elderly men have a low plasma cholinesterase which may prolong Sux
True
Delirium is a chronic/acute manifestation
acute
Dementia is a chronic/acute manifestation
chronic
You are about to do an RSI on a 75 yo male with a kidney stone who lives in a nursing home and hasn't been out of bed in months. What muscle relaxant will you use?
Rocuronium, don't want to use Sux because he has been immobile for quite awhile
Your patient is 82 yo and is having cataract surgery, has a history of CV disease & DM. As the surgeon is performing his retrobulbar block your patient suddenly becomes tachycardic, and hypertensive > 20% of baseline. What risk does your patient have r/t his history?
Risk of MI ( intraoperative myocardial ischemia associated with tachycardia, pain with procedure can cause high BP & HR setting pt up for MI)
An example of a non particulate antacid is
a) mylanta
b) sodium citrate
c) ranitidine
b) sodium citrate
An example of an H2 blocker is
a) ranitidine
b) omeprazole
c) metochlopromide
a) ranitidine
An example of a proton pump inhibitor is
a) famotidine
b) metochlopromide
c) omeprazole
c) omeprazole
An example of a prokinetic drug is
a) ranitidine
b) omeprazole
c) metochlopromide
c) metochlopromide
A prokinetic drug
a) increases gastric pH
b) increases gastric emptying
c) decreases gastric pH
d) decreases gastric emptying
b) increases gastric emptying
When intubating a pt with an unstable atlantoaxial joint what must you try to avoid?
Subluxing the joint as it can lead to decreased vertebral blood flow, compression of cord which may lead to "beauty parlor stroke"
During your pre-op your pt complains of tingling of their arms when you ask them to flex, extend & rotate their head what do you suspect?
possible atlantoaxial joint instability
When your pt is in the beach chair position what is important to remember
a) The BP in their arm will be lower than the pressure in their brain
b) The BP in their arm will be higher than the pressure in their brain
b) The BP in their arm will be higher than the pressure in their brain
Why is a regional anesthesia a better choice for orthopedic surgery, (especially in older folks)
a) decreased risk for DVT
b) decreased resp/CV depression
c) decreased PONV
d) both a & b but not c
e) all of the above
e) all of the above
What are the advantages of Deliberate Hypertension? Why would you use it in an orthopedic case?
reduce blood loss by 50%
provides dry bone surface for prosthesis
What drug(s) could you use for Deliberate Hypertension
a) NTG
b) Nipride
c) Ca Channel Blockers
d) Volatile agents
all answers are correct
What type of fracture(s)/surgeries put pt at risk for a fat embolism
a) fractured humerous
b) fractured femur
c) fractured ulna
d) fractured pelvis
fractured femur and pelvis
You are in the maintenance phase of your anesthetic on a young man with a femur fracture, everything is going along nicely and you notice that your pt's ETCO2 & SaO2 are dropping, your ventilator is alarming high peak airway pressure. What do you suspect?
a) Bone cement implantation syndrome ( methylmethatcrylate)
b) Fat embolism
c) Reactive hyperemia
Fat embolism, while you may have an decreased ETCO2 and SaO2 in bone cement syndrome you won't have the high peak airway pressures.
How would you treat a Fat embolism
a) supportive O2
b) positive pressure ventilation
c) prophyllactic heparin
d) all of the above
d) all of the above
True/False There a decreased risk of DVT with Regional anesthesia r/t vasodilation, increased blood flow in lower extremities secondary to sympathetic block
True
When using a tourniquet for orthopedic surgery how are the pressure limits for the tourniquet determined?
Get baseline BP and then inflate cuff 90 -100 mmHg above that pressure
NOTE upper ext pressure must not exceed 300 mmHg
lower ext must not exceed 500 mmHg
What is the maximum amount of time a tourniquet should be inflated?
a) 2 hours
b) 3 hours
c) as long as the case takes up to 6 hours
a) 2 hours
Before inflating the tourniquet what technique is used to exsanguinate the blood from the extremity
a) sellick technique
b) esmarch technique
c) gardner technique
b) esmarch technique
Which fiber would be associated with tourniquet pain?
a) c-fibers
b) a delta fibers
c) kappa fibers
a) c-fibers
Everything is going along smoothly during an I & D and repair of a tendon of your patients hand, there is very little blood loss ( b/c there is a tourniquet in place) tourniquet time is approaching 60 minutes. You have been watching your MAP & HR steadily increase, you suspect
a) light anesthesia
b) tourniquet pain
c) reactive hyperemia
b) tourniquet pain
When a tourniquet is released you might expect to see a transient
a) increased ETCO2
b) decreased BP
c) decreased HR
d) all of these as are s/s of reactive hyperemia
d) all of these as are s/s of reactive hyperemia
Your pt is a 75 yo Total hip arthroplasty, surgery is proceeding without any problem, you start to notice this very strong chemical odor, you look over the drape and see the surgeon is placing the cement in the joint, you should be prepared for
a) your pt's BP to drop
b) to wake your pt up surgery is about over
c) release the tourniquet
d) there is no concern for anything at this time
a) your pt's BP to drop
What is the concern when your patient is having methylmethacrylate cement placed in their Total joint? How might you try to compensate for it?
A sudden drop in BP

Adequate hydration and maximizing inspired O2 can minimize the hypotension and hypoxia that may occur
General anesthesia techniques include
a) ETT
b) LMA, face mask
c) nasal cannula
d) a & b only
e) a, b & c
e) a, b & c
In order to be considered MAC anethesia
a) pt must be able to respond verbally
b) you must give only versed & fentanyl
c) you can give no more than 50mcg of Fentanyl
pt must be able to respond verbally
True/False You can use propofol and still charge for a MAC case
True, but you could also charge for a general anesthesia if your pt requires airway assistance
Golden rule of anesthesia?
Always be ready to go to SLEEP!
Which pts might you NOT want to use a MAC technique on?
a) chronic pain pt
b) fibromyalgia
c) drug abusers
d) squirrels
all answers are correct!! you know i had to put the squirrels in there!!
Sedation for minor surgery might include
a) versed in 1-3mg increments
b) fentanyl 0 - 100 mcg (max)
c) propofol bolus 25 - 50 mg
d) all of the above
d) all of the above
Why might your diabetic pt require little to no pain medicine?
diabetic neuropathy
When you have your cart set up with the items you will need to go to sleep with in case your MAC isn't working, what would be important to add in addition to the blade, ETT, and Sux, if you were doing a kid?
Atropine
What is normal dose for propofol
a) 1 - 2 mg/kg
b) 2 - 4mg/kg
c) none of these
a) 1 - 2 mg/kg
How soon does propofol typically take to produce sedation?
a) 60 seconds
b) 30 seconds
c) 90 seconds
d) almost instantly
b) 30 seconds
What is the onset of versed?
a) 30 - 60 seconds
b) 60 - 90 seconds
c) immediate
a) 30 - 60 seconds
What is the duration of fentanyl
a) 30 - 60 minutes
b) 30 - 60 seconds
c) 2 - 3 hours
d) none of the above
a) 30 - 60 minutes for the first dose then difficult to determine d/t high volume of distribution
What are the s/s of oversedation?
excessive decrease in LOC
apnea
hypotension
dysphoria
agitation
True/False If your pt's BP starts dropping during a MAC case you could possibly increase the BP simply by opening your patients airway with a jaw thrust maneuver
True
If your MAC case becomes agitated or dysphoric possible causes could be
a) hypoxia
b) undersedation
c) a paradoxical response (kids)
d) all of the above
d) all of the above
In pt selection for surgery in an ODS, which infant would NOT be an appropriate candidate for surgery in ODS
a) premature infant gestational age < 37 weeks
b) full term infant that is 2 weeks old
c) infant with history of respiratory difficulties ( who is free of problems at time of surgery)
d) both a & c
a) premature infant gestational age < 37 weeks
True/False An infant who is 5 months old who has a sibling that died of SIDS is an appropriate candidate for ODS
False, not until they are between 6 months and 1 year are the considered possible candidates
True/False A pt with Malignant Hyperthermia Susceptibility is an absolute contraindication for surgery at an ODS center
False, but the pt should be scheduled early in day and be administered a trigger free anesthetic and be observed for at least 2.5 hrs postop
A premature infant has which of the following potential physiologic aberrations
a) anemia
b) undeveloped gag reflex
c) immature temperature control
d) all of the above
d) all of the above
Pts with obstructive sleep apnea are not considered for candidates for ODS if
a) they are having airway surgery
b) tonsillectomy in a child < 3 years old
c) laparoscopic surgery of upper abdomen
d) both a & b, but not c
e) a, b & c
e) a, b & c
When considering pts with sickle cell disease is sickle cell itself an absolute contraindication for ODS surgery?
No, but they should not have had an episode of sickle cell crisis in the last year, have no major organ disease, be compliant with prescribed medical care
When evaluating a pt for ODS surgery the evaluation should be conducted
a) within 30 days for healthy patients
b) within 72 hours for high-risk pts
c) within 72 hours for all patients (need to be able to evaluate for cold symptoms)
d) both a & b
d) both a & b
True/False children with URTI's are an absolute contraindication to having surgery in an ODS
False, N&P pg 901
True/False When considering ETT vs LMA in the ODS it may be more advantageous to use an LMA because ETT can delay patient discharge
True
True/False Earlier discharge from an ODS facility can be seen in fasting adult pts who receive 2L IVF
True
Advantages of regional anesthesia in the ODS setting include
a) shorter recovery time than those of GA
b) reduced unanticipated admission to hospital
c) immediate postop pain relief
d) decreased N/V, dizziness
e) all of the above
e) all of the above
Brachial plexus anesthesia can involve which approaches
a) axillary
b) popliteal
c) interscalene
d) supraclavicular
e) a, c & d
e) a, c & d
While regional anesthesia such as brachial plexus lends it self to earlier discharge from the ODS one of its drawbacks is_________________
length of time (longer than 15 minutes) required until complete anesthesia is achieved
True/False In order to decrease the amount of time it takes for a brachial plexus block to take effect, one could add Sodium Bicarb to either lidocaine or bupivacaine
False, there is no evidence that supports this
A supraclavicular block has a ______
chance of developing a pneumothorax than and interscalene block
a) lower
b) higher
c) equall
b) higher
The interscalene approach is associated with
a) intradural injection
b) vertebral artery puncture
c) stellate ganglion & recurrent laryngeal block
d) all of the above
e) c only
d) all of the above
True/False You can leave an indwelling brachial plexus catheter with continuous infusion of local anesthetic in place to help minimize post-op pain
True
Transient urinary retention is
a) caused by sympathetic and parasympathetic block
b) higher in male pts
c) influenced by duration of sympathetic block
d) all of the above
e) a & b only
d) all of the above
True/False Postoperative nausea and vomiting, and pain are the most common reasons for requiring hospitalization following surgery in ODS
True
If your patient is in reverse trendelenburg what hemodynamic changes might you see
a) increased venous return
b) improved pulmonary function
c) decreased venous return
d) both b & c
d) both b & c
During a laparoscopic abdominal procedure, (pneumoperitoneum), the max abdominal pressure should be
a) < 15 mmHg
b) < 20mmHg
c) < 25mmHg
a) < 15 mmHg